Polypharmacy is a term to describe patients who are taking multiple prescription medications, over the counter (OTC) drugs, and supplements in order to treat multiple conditions. Many of these are elderly patients.
In the ambulatory care setting, a generally accepted number of medications that describe polypharmacy is five prescriptions or more. In an inpatient or long term care setting that number is typically nine or more, but it’s not uncommon for elderly patients to be taking ten, twelve, fifteen or more prescription medications daily.
Although these medications are typically recommended by well-intentioned providers or clinicians, the sheer number of them increases the potential for drug-drug interactions, side effects, and other adverse events. That’s why it’s important for physicians to consider ways to prevent or at least improve the management of patient polypharmacy.
Here are some ways to do this.
1. Be militant about medication reconciliation
A first step in managing polypharmacy is to create a complete and accurate list of all medications a patient is taking. Oftentimes, however, this is easier said than done. In an emergency department or at inpatient admission, for example, it can take up to an hour or more to collect a complete list, which includes reason, dosage, and frequency. But diligence with conducting an accurate reconciliation is vital to patient safety and care. When patients are admitted with an incomplete or inaccurate medication list, they may be prescribed duplicate medications, or medications that can interact with an existing regimen. The result can be an interaction or adverse drug event during their stay and some that may continue after discharge.
Medication reconciliation is challenging in our busy clinics and hospitals, but it must be done at every appointment and care transition point to keep people on the right medicine, at the right dosage, at the right time - as well as to serve as a critical “stop-and-think” assessment to review and eliminate potentially unnecessary drugs.
2. Ask patients if they are being treated by other physicians and providers
Patients taking multiple medicines to manage multiple conditions are most likely being treated by multiple specialists and other providers. Without realizing it, each provider may take a condition or disease centric approach to prescribing. And patients may not understand, for instance, that the cardiologist needs to know about the pills that the pulmonologist and orthopedist prescribed.
Physicians can spur conversation with polypharmacy patients by asking whether they are being seen by other providers, and whether those providers have prescribed any medicines or supplements. Asking simple questions can provide another piece of the medication puzzle before a new prescription is written for something that may be contraindicated with a medicine the patient is already taken, but forgot to disclose.
3. Verify that there is an actual indication for every medication being taken
Simply put, every medication must map to a diagnosis or other indication, and be clearly communicated to the patient so he or she understands the reason for taking it. If not, physicians should question the purpose of the patient taking the medication at all. If there is no indication, “deprescribing” may be in order. Deprescribing is the process of intentionally stopping a medication or reducing its dose to improve the person's health or reduce the risk of adverse side effects.
4. Assess deprescribing opportunities at every visit or care transition
Patients age, conditions change. Physicians should conduct a systematic, one-on-one review of polypharmacy patient regimens with the goal of simplifying, deprescribing, or modifying medication regimens while still maintaining efficacy. Ask questions about the purpose of each medication.
For instance, does the advanced stage Alzheimer’s patient still need to be on donepezil and memantine? Does a patient who pulled a back muscle hiking three months ago still need to be taking six ibuprofen each day? Take a critical look at each medicine and whether it can be discontinued, or titrated down. Use tools such as the The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, updated by the American Geriatrics Society. Every clinician’s goal should be to have patients on the least amount of medications that deliver the highest amount of therapeutic good.
5. Involve a pharmacist
Pharmacists can provide insights into a patient’s regimen from a pharmacologic perspective, and recommend medications that can be removed and/or dosages that should be modified. Engage them in the review of polypharmacy patient medications and care.
6. Use technology tools that deliver accurate prescription data
As any clinician will attest, patients are the worst historians of the medications they are taking. Few can accurately recall the name and dosage of all the medicines they are taking. And while a “brown bag review” of all the patient’s pill bottles certain improves accuracy, it’s not convenient for the patient to take medicines to every physician appointment.
Yet, the most common practice for determining a patient’s medication list is still to ask the patient.
Tools like Cureatr’s Meds360 provides physicians with accurate real-time medication data, derived from data feeds of actual pharmacy purchases. In one, 12-month view providers can see which prescriptions, by therapeutic class, a patient has filled or not filled, dosage changes, duplicate medications, and more. Data like this fills patient memory gaps and EHR inconsistencies, making it easier for physicians to determine which medications the patient may or may not need to continue taking.
7. Try behavior modification strategies before adding a new drug
These could include exercise and dietary changes for patients with diabetes or certain cardiovascular conditions, art and music for patients with dementia or depression, or cooking classes for patients with diabetes or obesity. And, many residential communities offer pet and aromatherapy programs, or learning opportunities for residents. Physicians should inquire about and encourage things like these, which provide an opportunity for condition improvement without drug intervention.